Privately run, long-term managed care programs aim to ease the burdens that come with treating Medicaid and dual-eligible beneficiaries in skilled nursing facilities. Finding ways to treat people in their homes or in community-based care facilities is not just about controlling costs; the aging population is growing, people are living longer, and many are now surviving disabling conditions. There’s simply no room to treat them all in skilled nursing homes.

In fact, a recent report from Avalere Health projects that three-fourths of Medicaid beneficiaries will receive benefits through a managed care organization (MCO) by 2015. The capitated payment model of a MCO provides incentives for value-based care not found in the traditional Medicare fee-for-service (FFS) model.

“We believe that Medicaid managed care is a new way to use the money and use the resources much better in every community,” said Larry Minnix, CEO and president of LeadingAge, the nation's largest association of not-for-profit long-term care providers.

However, the future of long-term managed care is uncertain. Some plans may limit options, and patients may find that they are no longer eligible for care they once were under the FFS model. Take, for instance, that Mr Glenn McClanahan, a beneficiary in Tenneessee, originally qualified for at-home care through TennCare Choices for his chronic arthritis and emphysema. His care cost an estimated $3800 per month in comparison to the $4600 Medicaid would have paid for him to be cared for at a nursing home. However, when he was later diagnosed with dementia, the state and the insurer denied his application for nursing care. He also lost his home care. This was due to Tennessee’s scoring system, which raised the requirements for nursing home admissions. Only after sustaining injuries was Mr McClanahan granted coverage.

However, Patti Killingsworth, an assistant commissioner with TennCare Choices, said the agency is working to address the needs and concerns of patients like Mr McClanahan.

“The value of today is that we are able to hear some specific recommendations and ideas about things we can do to improve the process,” said Ms Killingsworth. “We are always looking for those. I’ve made a commitment both to the people who presented that testimony and to the chairman that we are going to sit down and evaluate those things as we do on a constant basis and figure out if there are improvements that can be made either in the criteria or the process.”

Around the Web

Pitfalls Seen in a Turn to Privately Run Long-Term Care [The NY Times]